Psychotherapy Carolyn R. Fallahi, Ph. D.

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Psychoanalysis

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Humanistic Therapy

Cognitive-Behavioral Therapy

Evidence-based practice

Theory of Psychoanalysis • Psychoanalysis = both a theory of personality and a psychotherapy. • The theory of personality calls upon: – Unconscious forces – Repression – Libidinal drives – Infantile sexuality – Id, ego, superego • The theory of personality calls upon: – Freeing psychic energy bound up in unconscious conflicts due to repressed unconscious impulses and resultant anxiety – Resistance and transference

Key concepts • • • • • • •

Psychodynamics Levels of consciousness Personality structures Psychosexual stages of development Dynamics Libido Levels of consciousness – – – –

Conscious mind Preconscious Unconscious Repression

ID

Superego Ego

Oral Stage Anal Stage

Phallic Stage Latency Stage

Genital Stage

The Psychosexual Stages

Fixation, Repression • What is fixation? • The theory of repression = the cornerstone for psychoanalysis – Amnesia? – Do they really forget?

What constitutes normal? • Normal behavior = free of intrapsychic conflicts. • Normal? – Passed through psychosexual stages successfully. – Enough libidinal energy available.

• What constitutes abnormal behavior? • Psychopathology associated with: – Oral stage – Phallic stage – Post-Odeipal phase

Transference & Countertransference • What is transference? • What is countertransference? • The amount of distortion of reality = the intensity of pathology. • How should an analyst handle countertransference?

Methods for dealing with repression • • • •

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Dream analysis Free association Hypnosis What type of patient works best with psychoanalysis? How is assessment handled? How long should a patient be in therapy? What is the role of the therapist? What are the goals for the patient?

Therapeutic Techniques • The techniques used by the therapist: – Confrontation – Clarification – Interpretation of repeated patterns of thinking, feeling, and behaving = repetition compulsion. – Patients become aware of how his/her early relationships affect his/her current functioning. – Use the patient’s resistance as a road map to unconscious conflict. What are the ways in which patients show resistance? How can a therapist break through resistance?

How do we know that the patient has been cured? • Elimination of symptoms? • The interpretation is repeated to effectively break through the associations being kept unconscious by inner affective resistance.

Research Directions of Classical Psychoanalysis • • • •

Evidence is sparse. No compelling evidence to show = effective. Early research = case studies. Problems? Longitudinal studies of psychoanalysis – 1941 – 543 analytic clients showed that 60% patients cured / improved. – Meninger Psychotherapy Research Project Study 1952 – 42 patients followed for 30 years. – Limitations with this research.

Psychoanalysis does diversity! • Classical psychoanalysis – theory, practice, and research – is a product of Western culture and aimed at those with that worldview. • Who practices psychoanalysis? • Freud and women • Major critiques

Roger’s Client-centered therapy Carolyn R. Fallahi, Ph. D.

Historical context • 1950s and 1960s – key concepts find their way into psychotherapy. • Complaints about earlier models. • Philosophical roots of Humanism • Humanistic psychotherapies – what do they have in common? • Person-centered therapy – Nondirective therapy – Client-centered – Carl Rogers

Key concepts • • • • • • • • • •

Self-actualization The self The real or actual self The ideal self Congruence and incongruence Unconditional positive regard Conditions of worth Locus of evaluation Genuineness and empathy Empathic listening

Normal and abnormal behavior • How do we define normal versus abnormal behavior? • Who is an example of a fully functioning person? • Abnormality – why? • Assessment and diagnosis • The therapeutic relationship • What does the therapist do? • What does the client do? • Therapeutic techniques used.

The process of therapy • • • • • • • • •

The course of therapy Verbal discourse Feelings Experiencing Incongruence Cognitive mapping of experience Problems Relationships Termination

Research Directions of ClientCentered Therapy • Problems with the research associated with Roger’s work. • It’s old, theoretical. • Verbatim records of sessions • Q-sort • Process studies • Outcome studies • Criticisms • The practice of client-centered therapy • More recent research

Humanism Therapy • An example of a case study.

Childhood Traumatic Grief • New childhood condition – Childhood Traumatic Grief (CTG). • Conceptualization • Symptoms • Coping Mechanism

Other Common Symptoms • depression or anxiety. • Issues with internalizing or externalizing behaviors. • Similar to loss of a parent through divorce. • Higher incidence of “interpersonal sensitivity”.

Examples • 1998 hurricane that killed 4,000 people in Nicaragua. • 9/11 examples. • Virginia Tech examples.

Client-Centered Treatment – Carl Rogers

The role of the therapist • Provides assistance based on certain beliefs – the person is valuable, worthwhile, and fully equipped to understand her life. • Techniques used. • The challenge for the therapist.

Traumagenic Model • The use of CCT is especially compatible with Finkelhor & Browne’s traumagenic model. • What is the traumagenic model? • What symptoms are common in children & adolescents?

Case Study • The case of Shelly – a 15-year-old high school sophomore at a large public high school. • Development history was unremarkable. • No previous history of mental health problems.

Case Study • Honor student. • Small, close group of friends from elementary school. • No hobbies & was not on any sports teams. • Shelly told her mother that 6 months after the death of her father, she needed help. • In the pretreatment evaluation, Shelly seemed to vacillate between attempting to control her feelings & being overwhelmed by them. • She appeared to function well when provided structure, as in school.

Case Study • Both Shelly & mom felt that they were arguing more. • Adjustment disorder – diagnosis. • Shelly also reported a number of symptoms of PTSD, including 4/5 arousal symptoms, 4/5 reexperiencing symptoms, & depression & anxiety. • Based on Shelly’s symptoms & reported difficulties in various areas of her life, she was seen as having CTG. • Positive long-term outcome was seen because she did not have any pre-event mental health problems & her mother was asymptomatic for PTSD. Both mother & child had strong support networks.

What is going on with psychotherapy today? Carolyn R. Fallahi, Ph. D.

Empirically Supported/Validated Therapy • APA’s Division 12 Task Force on the Promotion and Dissemination for Psychological procedures has published a list of empirically validated treatments illustrating that there are efficacious treatments for specific psychological problems. • What do critics say? • Randomized control trials • Efficacy versus effectiveness • Evidence-based practice (EBP)

Steps recommended by an Evidence-based approach (Austad, 2008)

• “1) Pose a clinically relevant and specific focused question about the care of a particular patient (e.g. which is the better treatment for major depression – therapy or medication? • 2) search on the internet for the evidence that best answers the question (or ascertains that there is no research available). The literature sources are multiple, but some are evidencebased reviews, such as the Cochrane collaboration. • 3) Select an article (or more) that contains the information that can answer your question.

Steps recommended by an Evidence-based approach • 4) Evaluate and bring the research study to the level of direct patient care. – Validity: is the study valid? How sure can we be that the results are due to the treatments and not to some other, uncontrolled variable? From most likely to least likely to be valid are systematic reviews and general information about therapy; meta-analysis, randomized controlled studies; cohort studies; cross-control studies; cross-sectional studies; case reports. – Outcomes: what were the result of the study? Based on outcome measures and rating scales used, can you calculate magnitude of improvement? Did the patient move into the normal range of functioning?

Steps recommended by an Evidence-based approach • 4) Evaluate and bring the research study to the level of direct patient care. – Safety: is the treatment safe? – Meaningfulness: are the results clinically meaningful/ an the results of the clinical trial be applied to the individual patient? – Applicability: is the result applicable to the patient? Is the patient represented in the research sample? How were the outcomes measured? Can I apply the treatment in my practice?”

What do practicing Psychologists think about EBP? • Those in favor of EBP • Those opposed